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Rapid response to:

Clinical Review

Tick bite prevention and tick removal

BMJ 2013; 347 doi: (Published 09 December 2013) Cite this as: BMJ 2013;347:f7123

Rapid Response:

Re: Tick bite prevention and tick removal

Due and colleagues [1] provide an insightful overview regarding tick bite prevention and tick removal. We were delightful for the attention given to preventing tick bites and we would like to raise three related matters.

First, preventive strategies regarding ticks and their possible consequences include multiple behaviours, e.g., the avoidance of tick-infested areas, the use of protective clothing (e.g., wearing long-sleeved shirts and long trouser pants, which reduce the area of exposed skin), routine body checks for ticks after being outdoors, and the use of tick repellents on either the skin or clothing. Except for body checks, these measures are not well accepted by the general public [2] and compliance is low [3].

Second, each of these behaviours has different determinants. For example, people believe that these protective clothing interfere with how they want to enjoy nature (e.g., they refuse to wear long clothes on a hot day), people do not believe that tick repellents are an effective way to prevent tick bites, and people do not know how to identify a tick bite (which is crucial for removing a tick) [2,4]. Insight into determinants underlying preventive behaviours is essential for increasing the likelihood of developing effective health education material [5].

Third, at present, health education materials as well as prevention research regarding tick bites mainly focus on adults. Several studies pointed to children as a distinct and vulnerable risk group [6,7]. Although parents are the designated persons to check children for ticks, the need for checking should be communicated directly to children as well [6]. Teaching them to recognise the tiny nymphal stage of ticks and the features of tick habitats can encourage them to urge parents to do timely body checks [7]. Therefore it seems logical to develop health education materials aimed at both children and their parents. Again, insight into determinants of children’s’ behaviour (e.g., asking their parents to do a body check) should be used in the development of such health education materials [8].


[1] Due C, Fox W, Medlock JM, Pietzsch M, Logan JG. Tick bite prevention and tick removal. BMJ 2013;347:f7123.

[2] Beaujean DJ, Bults M, van Steenbergen JE, Voeten HA. Study on public perceptions and protective behaviors regarding Lyme disease among the general public in the Netherlands: implications for prevention programs. BMC Public Health 2013;13:225.

[3] Daltroy LH, Phillips C, Lew R, Wright E, Shadick NA, Liang MH. A controlled trial of a novel primary prevention program for Lyme disease and other tick-borne illnesses. Health Educ Behav 2007;34:531-542.

[4] Marcu A, Uzzell D, Barnett J. Making sense of unfamiliar risks in the countryside: the case of Lyme disease. Health Place 2011;17:843-850.

[5] Kok G, Schaalma H, Ruiter RA, van Empelen P, Brug J. Intervention mapping: protocol for applying health psychology theory to prevention programmes. J Health Psychol 2004;9:85-98.

[6] Klein JD, Eppes SC, Hunt P. Evironmental and life-style risk factors for Lyme disease in children. Clin Pediatr 1996;35:359-363.

[7] Rizolli A, Hauffe HC, Carpi G, Vourc’h GI, Neteler M, Rosà R. Lyme borreliosis in Europe. Euro Surveill 2011;16:pii=19906.

[8] de Vries H, van Dillen S. Prevention of Lyme disease in Dutch children: analysis of determinants of tick inspection by parents. Prev Med 2002;35:160–165.

[9] Eisen R, Piesman JJ, Zielinski-Gutierrez E, Eisen L. What do we need to know about disease ecology to prevent Lyme disease in the northeastern United States? J Med Entomol 2012;49:11–22.

[10] Beaujean DJ, Gassner F, Wong A, Steenbergen van JE, Crutzen R, Ruwaard D. Determinants and protective behaviours regarding tick bites among school children in the Netherlands: a cross-sectional study. BMC Public Health 2013;13:1148.

Competing interests: No competing interests

15 December 2013
Rik Crutzen
Senior researcher
Desirée Beaujean
Maastricht University/CAPHRI
P.O. Box 616, 6200 MD Maastricht, the Netherlands